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1 IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF VIRGINIA Richmond Division UNITED STATES OF AMERICA, ) ) Plaintiff, ) ) CIVIL ACTION NO: v. ) ) COMMONWEALTH OF VIRGINIA, ) ) Defendant. ) ) ) I. Introduction SETTLEMENT AGREEMENT A. The Commonwealth of Virginia ( the Commonwealth ) and the United States (together, the Parties ) are committed to full compliance with Title II of the Americans with Disabilities Act ( ADA ), 42 U.S.C , as interpreted by Olmstead v. L.C., 527 U.S. 581 (1999). This Agreement is intended to ensure the Commonwealth s compliance with the ADA and Olmstead, which require that, to the extent the Commonwealth offers services to individuals with intellectual and developmental disabilities, such services shall be provided in the most integrated setting appropriate to meet their needs. Accordingly, throughout this document, the Parties intend that the goals of community integration, self-determination, and quality services will be achieved. B. On August 21, 2008, the United States Department of Justice ( United States ) initiated an investigation of Central Virginia Training Center ( CVTC ), the largest of Virginia s five state-operated intermediate care facilities for persons with intellectual and developmental disabilities ( ICFs ), pursuant to the Civil Rights of Institutionalized Persons Act ( CRIPA ), 42 U.S.C On April 21, 2010, the United States notified the Commonwealth that it was expanding its investigation under the ADA to focus on the Commonwealth s compliance with the ADA s integration mandate and Olmstead with respect to individuals at CVTC. During the course of the expanded investigation, however, it became clear that an examination of the Commonwealth s measures to address the rights of individuals at CVTC under the ADA and Olmstead implicated the statewide system for serving individuals with intellectual and developmental disabilities and required a broader scope of review. Accordingly, the policies and practices that the United States examined in its expanded investigation were statewide in scope and application. On February 10, 2011, the United States issued its findings, concluding that the Commonwealth fails to provide services to individuals with intellectual and 1

2 developmental disabilities in the most integrated setting appropriate to their needs as required by the ADA and Olmstead. C. The Commonwealth engaged with the United States in open dialogue about the allegations and worked with the United States to resolve the alleged violations of the ADA arising out of the Commonwealth s provision of services for individuals with intellectual and developmental disabilities. D. In order to resolve all issues pending between the Parties without the expense, risks, delays, and uncertainties of litigation, the United States and the Commonwealth agree to the terms of this Settlement Agreement as stated below. This Agreement resolves the United States investigation of CVTC, as well as its broader examination of the Commonwealth s compliance with the ADA and Olmstead with respect to individuals with intellectual and developmental disabilities. E. By entering into this Settlement Agreement, the Commonwealth does not admit to the truth or validity of any claim made against it by the United States. F. The Parties acknowledge that the Court has jurisdiction over this case and authority to enter this Settlement Agreement and to enforce its terms as set forth herein. G. No person or entity is intended to be a third-party beneficiary of the provisions of this Settlement Agreement for purposes of any other civil, criminal, or administrative action, and, accordingly, no person or entity may assert any claim or right as a beneficiary or protected class under this Settlement Agreement in any separate action. This Settlement Agreement is not intended to impair or expand the right of any person or organization to seek relief against the Commonwealth or their officials, employees, or agents. H. The Court has jurisdiction over this action pursuant to 28 U.S.C. 1331; 28 U.S.C. 1345; and 42 U.S.C Venue is proper in this district pursuant to 28 U.S.C. 1391(b). II. Definitions A. Developmental disability means a severe, chronic disability of an individual that: (1) is attributable to a mental or physical impairment or combination of mental and physical impairments; (2) is manifested before the individual attains age 22; (3) is likely to continue indefinitely; (4) results in substantial functional limitations in 3 or more of the following areas of major life activity: (a) self-care; (b) receptive and expressive language; (c) learning; (d) mobility; (e) self-direction; (f) capacity for independent living; (g) economic self-sufficiency; and (5) reflects the individual s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance that are of lifelong or extended duration and are individually planned and coordinated. 42 U.S.C B. Intellectual disability means a disability characterized by significant limitations both in intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior, which covers a range of everyday social and practical skills. This disability originates before the age of 18. An intellectual disability is a type of developmental disability. 2

3 C. Home and Community-Based Services Waivers ( HCBS Waivers ) means the program approved by the Centers for Medicare and Medicaid Services ( CMS ) for the purpose of providing services in community settings for eligible persons with developmental disabilities who would otherwise be served in ICFs. For purposes of this Settlement Agreement, HCBS Waivers includes the Intellectual Disabilities Waiver ( ID Waiver ) and the Individual and Family Developmental Disabilities Support Waiver ( DD Waiver ), or any other CMS approved waivers that are equivalent to the ID or DD Waivers that may be created after the execution of this Agreement. D. Individual and family supports are defined as a comprehensive and coordinated set of strategies that are designed to ensure that families who are assisting family members with intellectual or developmental disabilities ( ID/DD ) or individuals with ID/DD who live independently have access to person-centered and family-centered resources, supports, services and other assistance. Individual and family supports are targeted to individuals not already receiving services under HCBS waivers, as defined in Section II.C above. The family supports provided under this Agreement shall not supplant or in any way limit the availability of services provided through the Elderly or Disabled with Consumer Direction ( EDCD ) waiver, Early and Periodic Screening, Diagnosis and Treatment ( EPSDT ), or similar programs. III.Serving Individuals with Developmental Disabilities In the Most Integrated Setting A. To prevent the unnecessary institutionalization of individuals with ID/DD and to provide them opportunities to live in the most integrated settings appropriate to their needs consistent with their informed choice, the Commonwealth shall develop and provide the community services described in this Section. B. Target Population: 1. The target population of this Agreement shall include individuals with ID/DD who meet any of the following additional criteria: a. are currently residing at any of the Training Centers; b. who (i) meet the criteria for the wait list for the ID waiver, or (ii) meet the criteria for the wait list for the DD waiver; or c. currently reside in a nursing home or ICF. 2. The Commonwealth shall not exclude any otherwise qualifying individual from the target population due to the existence of complex behavioral or medical needs or of co-occurring conditions, including but not limited to, mental illness, traumatic brain injuries, or other neurological conditions. 3. Individuals shall remain in the target population if they receive HCBS waiver services or individual and family supports under this Agreement. 4. Individuals who are otherwise in the target population and who have been released from forensic status or placed on conditional release by a court shall not be excluded 3

4 from the target population solely on the basis of their former forensic status or current conditional release status. 5. Inclusion in the target population does not guarantee or create a right to receipt of services. C. Enhancement of Community Services 1. By June 30, 2021, the Commonwealth shall create 4,170 waiver slots for the target population, to be broken down as follows: a. The Commonwealth shall create a minimum of 805 waiver slots to enable individuals in the target population in the Training Centers to transition to the community according to the following schedule: i. In State Fiscal Year 2012, 60 waiver slots ii. iii. iv. In State Fiscal Year 2013, 160 waiver slots In State Fiscal Year 2014, 160 waiver slots In State Fiscal Year 2015, 90 waiver slots v. In State Fiscal Year 2016, 85 waiver slots vi. In State Fiscal Year 2017, 90 waiver slots vii. In State Fiscal Year 2018, 90 waiver slots viii. In State Fiscal Year 2019, 35 waiver slots ix. In State Fiscal Year 2020, 35 waiver slots b. The Commonwealth shall create a minimum of 2,915 waiver slots to prevent the institutionalization of individuals with intellectual disabilities in the target population who are on the urgent waitlist for a waiver, or to transition to the community individuals with intellectual disabilities under 22 years of age from institutions other than the Training Centers (i.e., ICFs and nursing facilities), according to the following schedule: i. In State Fiscal Year 2012, 275 waiver slots ii. iii. In State Fiscal Year 2013, 225 waiver slots, including 25 slots prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs In State Fiscal Year 2014, 225 waiver slots, including 25 slots prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs 4

5 iv. In State Fiscal Year 2015, 250 waiver slots, including 25 slots prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs v. In State Fiscal Year 2016, 275 waiver slots, including 25 slots prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs vi. In State Fiscal Year 2017, 300 waiver slots vii. In State Fiscal Year 2018, 325 waiver slots viii. In State Fiscal Year 2019, 325 waiver slots ix. In State Fiscal Year 2020, 355 waiver slots x. In State Fiscal Year 2021, 360 waiver slots c. The Commonwealth shall create a minimum of 450 waiver slots to prevent the institutionalization of individuals with developmental disabilities other than intellectual disabilities in the target population who are on the waitlist for a waiver, or to transition to the community individuals with developmental disabilities other than intellectual disabilities under 22 years of age from institutions other than the Training Centers (i.e., ICFs and nursing facilities), according to the following schedule: i. In State Fiscal Year 2012, 150 waiver slots ii. iii. iv. In State Fiscal Year 2013, 25 waiver slots, including 15 prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs In State Fiscal Year 2014, 25 waiver slots, including 15 prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs In State Fiscal Year 2015, 25 waiver slots, including 15 prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs v. In State Fiscal Year 2016, 25 waiver slots, including 15 prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs vi. In State Fiscal Year 2017, 25 waiver slots, including 10 prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs 5

6 vii. In State Fiscal Year 2018, 25 waiver slots, including 10 prioritized for individuals under 22 years of age residing in nursing homes and the largest ICFs viii. In State Fiscal Year 2019, 25 waiver slots ix. In State Fiscal Year 2020, 50 waiver slots x. In State Fiscal Year 2021, 75 waiver slots d. If the Commonwealth creates more waiver slots than are required in Sections III.C.1.a, b, or c above for a particular fiscal year, the number of slots created above the requirement shall be counted towards the slots required to be created in the subsequent fiscal year in the relevant Section. 2. The Commonwealth shall create an individual and family support program for individuals with ID/DD whom the Commonwealth determines to be most at risk of institutionalization, according to the following schedule: a. In State Fiscal Year 2013, a minimum of 700 individuals supported b. In State Fiscal Year 2014, a minimum of 1000 individuals supported c. In State Fiscal Year 2015, a minimum of 1000 individuals supported d. In State Fiscal Year 2016, a minimum of 1000 individuals supported e. In State Fiscal Year 2017, a minimum of 1000 individuals supported f. In State Fiscal Year 2018, a minimum of 1000 individuals supported g. In State Fiscal Year 2019, a minimum of 1000 individuals supported h. In State Fiscal Year 2020, a minimum of 1000 individuals supported i. In State Fiscal Year 2021, a minimum of 1000 individuals supported 3. If the Commonwealth substantially changes or amends its ID or DD waivers, the Parties shall meet within 15 days of final approval from CMS to determine if any provisions of this Agreement should be amended. The Parties agree that under any new terms, at least as many individuals in each category in Sections III.C.1.a, b, and c and C.2 above shall receive HCBS waivers and individual and family supports under the Agreement. If the Parties cannot reach agreement within 90 days, the Court shall resolve the dispute. 4. With the consent of the United States and the Independent Reviewer, the Commonwealth may re-allocate any unused waiver slot from one category of III.C.1.a-c to another in any State Fiscal Year covered by this Agreement. 5. Case Management 6

7 a. The Commonwealth shall ensure that individuals receiving HCBS waiver services under this Agreement receive case management. b. For the purposes of this agreement, case management shall mean: i. Assembling professionals and nonprofessionals who provide individualized supports, as well as the individual being served and other persons important to the individual being served, who, through their combined expertise and involvement, develop Individual Support Plans ( ISP ) that are individualized, person-centered, and meet the individual s needs; ii. Assisting the individual to gain access to needed medical, social, education, transportation, housing, nutritional, therapeutic, behavioral, psychiatric, nursing, personal care, respite, and other services identified in the ISP; and iii. Monitoring the ISP to make timely additional referrals, service changes, and amendments to the plans as needed. c. Case management shall be provided to all individuals receiving HCBS waiver services under this Agreement by case managers who are not directly providing such services to the individual or supervising the provision of such services. The Commonwealth shall include a provision in the Community Services Board ( CSB ) Performance Contract that requires CSB case managers to give individuals a choice of service providers from which the individual may receive approved waiver services and to present practicable options of service providers based on the preferences of the individual, including both CSB and non-csb providers. d. The Commonwealth shall establish a mechanism to monitor compliance with performance standards. 6. Crisis Services a. The Commonwealth shall develop a statewide crisis system for individuals with intellectual and developmental disabilities. The crisis system shall: i. Provide timely and accessible support to individuals with intellectual and developmental disabilities who are experiencing crises, including crises due to behavioral or psychiatric issues, and to their families; ii. Provide services focused on crisis prevention and proactive planning to avoid potential crises; and iii. Provide in-home and community-based crisis services that are directed at resolving crises and preventing the removal of the individual from his or her current placement whenever practicable. b. The crisis system shall include the following components: i. Crisis Point of Entry 7

8 A. The Commonwealth shall utilize existing CSB Emergency Services, including existing CSB hotlines, for individuals to access information about and referrals to local resources. Such hotlines shall be operated 24 hours per day, 7 days per week and staffed with clinical professionals who are able to assess crises by phone and assist the caller in identifying and connecting with local services. Where necessary, the crisis hotline will dispatch at least one mobile crisis team member who is adequately trained to address the crisis. B. By June 30, 2012, the Commonwealth shall train CSB Emergency Services personnel in each Health Planning Region ( Region ) on the new crisis response system it is establishing, how to make referrals, and the resources that are available. ii. Mobile crisis teams A. Mobile crisis team members adequately trained to address the crisis shall respond to individuals at their homes and in other community settings and offer timely assessment, services, support, and treatment to de-escalate crises without removing individuals from their current placement whenever possible. B. Mobile crisis teams shall assist with crisis planning and identifying strategies for preventing future crises and may also provide enhanced short-term capacity within an individual s home or other community setting. C. Mobile crisis team members adequately trained to address the crisis also shall work with law enforcement personnel to respond if an individual with ID/DD comes into contact with law enforcement. D. Mobile crisis teams shall be available 24 hours per day, 7 days per week and to respond on-site to crises. E. Mobile crisis teams shall provide local and timely in-home crisis support for up to 3 days, with the possibility of an additional period of up to 3 days upon review by the Regional Mobile Crisis Team Coordinator. F. By June 30, 2012, the Commonwealth shall have at least one mobile crisis team in each Region that shall respond to on-site crises within three hours. G. By June 30, 2013, the Commonwealth shall have at least two mobile crisis teams in each Region that shall respond to on-site crises within two hours. H. By June 30, 2014, the Commonwealth shall have a sufficient number of mobile crisis teams in each Region to respond on site to crises as follows: in urban areas, within one hour, and in rural areas, within two hours, as measured by the average annual response time. 8

9 iii. Crisis stabilization programs A. Crisis stabilization programs offer a short-term alternative to institutionalization or hospitalization for individuals who need inpatient stabilization services. B. Crisis stabilization programs shall be used as a last resort. The State shall ensure that, prior to transferring an individual to a crisis stabilization program, the mobile crisis team, in collaboration with the provider, has first attempted to resolve the crisis to avoid an out-of-home placement and if that is not possible, has then attempted to locate another communitybased placement that could serve as a short-term placement. C. If an individual receives crisis stabilization services in a community-based placement instead of a crisis stabilization unit, the individual may be given the option of remaining in the placement if the provider is willing and has capacity to serve the individual and the provider can meet the needs of the individual as determined by the provider and the individual s case manager. D. Crisis stabilization programs shall have no more than six beds and lengths of stay shall not exceed 30 days. E. With the exception of the Pathways Program operated at Southwestern Virginia Training Center ( SWVTC ), crisis stabilization programs shall not be located on the grounds of the Training Centers or hospitals with inpatient psychiatric beds. By July 1, 2015, the Pathways Program at SWVTC will cease providing crisis stabilization services and shall be replaced by off-site crisis stabilization programs with sufficient capacity to meet the needs of the target population in that Region. F. By June 30, 2012, the Commonwealth shall develop one crisis stabilization program in each Region. G. By June 30, 2013, the Commonwealth shall develop an additional crisis stabilization program in each Region as determined necessary by the Commonwealth to meet the needs of the target population in that Region. 7. Integrated Day Activities and Supported Employment a. To the greatest extent practicable, the Commonwealth shall provide individuals in the target population receiving services under this Agreement with integrated day opportunities, including supported employment. b. The Commonwealth shall maintain its membership in the State Employment Leadership Network ( SELN ) established by the National Association of State Developmental Disability Directors. The Commonwealth shall establish a state policy on Employment First for the target population and include a term in the CSB Performance Contract requiring application of this policy. The Employment 9

10 First policy shall, at a minimum, be based on the following principles: (1) individual supported employment in integrated work settings is the first and priority service option for individuals with intellectual or developmental disabilities receiving day program or employment services from or funded by the Commonwealth; (2) the goal of employment services is to support individuals in integrated work settings where they are paid minimum or competitive wages; and (3) employment services and goals must be developed and discussed at least annually through a person-centered planning process and included in ISPs. The Commonwealth shall have at least one employment service coordinator to monitor implementation of Employment First practices for individuals in the target population. i. Within 180 days of this Agreement, the Commonwealth shall develop, as part of its Employment First policy, an implementation plan to increase integrated day opportunities for individuals in the target population, including supported employment, community volunteer activities, community recreational opportunities, and other integrated day activities. The plan will be under the direct supervision of a dedicated employment service coordinator for the Commonwealth and shall: A. Provide regional training on the Employment First policy and strategies throughout the Commonwealth; and B. Establish, for individuals receiving services through the HCBS waivers: 1. Annual baseline information regarding: a. The number of individuals who are receiving supported employment; b. The length of time people maintain employment in integrated work settings; c. Amount of earnings from supported employment; d. The number of individuals in pre-vocational services as defined in 12 VAC in effect on the effective date of this Agreement; and e. The length of time individuals remain in pre-vocational services. 2. Targets to meaningfully increase: a. The number of individuals who enroll in supported employment each year; and b. The number of individuals who remain employed in integrated work settings at least 12 months after the start of supported employment. 10

11 c. Regional Quality Councils, described in Section V.D.5 below, shall review data regarding the extent to which the targets identified in Section III.C.7.b.i.B.2 above are being met. These data shall be provided quarterly to the Regional Quality Councils and the Quality Management system by the providers. Regional Quality Councils shall consult with those providers and the SELN regarding the need to take additional measures to further enhance these services. d. The Regional Quality Councils shall annually review the targets set pursuant to Section III.C.7.b.i.B.2 above and shall work with providers and the SELN in determining whether the targets should be adjusted upward. 8. Access and Availability of Services a. The Commonwealth shall provide transportation to individuals receiving HCBS waiver services in the target population in accordance with the Commonwealth s HCBS Waivers. b. The Commonwealth shall publish guidelines for families seeking intellectual and developmental disability services on how and where to apply for and obtain services. The guidelines will be updated annually and will be provided to appropriate agencies for use in directing individuals in the target population to the correct point of entry to access services. 9. The Commonwealth has made public its long-standing goal and policy, independent of and adopted prior to this Agreement or the Department of Justice s findings, of transitioning from an institutional model of care to a community-based system that meets the needs of all individuals with ID/DD, including those with the most complex needs, and of using its limited resources to serve effectively the greatest number of individuals with ID/DD. This goal and policy have resulted in a decline in the population of the state training centers from approximately 6000 individuals to approximately 1000 individuals. The Commonwealth has determined that this significant and ongoing decline makes continued operation of residential services fiscally impractical. Consequently, and in accordance with the Commonwealth s policy of transitioning its system of developmental services to a community-based system, the Commonwealth will provide to the General Assembly within one year of the effective date of this Agreement, a plan, developed in consultation with the Chairmen of Virginia s House of Delegates Appropriations and Senate Finance Committees, to cease residential operations at four of the five training centers by the end of State Fiscal Year D. Community Living Options 1. The Commonwealth shall serve individuals in the target population in the most integrated setting consistent with their informed choice and needs. 2. The Commonwealth shall facilitate individuals receiving HCBS waivers under this Agreement to live in their own home, leased apartment, or family s home, when such a placement is their informed choice and the most integrated setting appropriate to their needs. To facilitate individuals living independently in their own home or 11

12 apartment, the Commonwealth shall provide information about and make appropriate referrals for individuals to apply for rental or housing assistance and bridge funding through all existing sources, including local, State, or federal affordable housing or rental assistance programs (tenant-based or project-based) and the fund described in Section III.D.4 below. 3. Within 365 days of this Agreement, the Commonwealth shall develop a plan to increase access to independent living options such as individuals own homes or apartments. The Commonwealth undertakes this initiative recognizing that comparatively modest housing supports often can enable individuals to live successfully in the most integrated settings appropriate to their needs. a. The plan will be developed under the direct supervision of a dedicated housing service coordinator for the Department of Behavioral Health and Developmental Services ( DBHDS ) and in coordination with representatives from the Department of Medical Assistance Services ( DMAS ), Virginia Board for People with Disabilities, Virginia Housing Development Authority, Virginia Department of Housing and Community Development, and other organizations as determined appropriate by DBHDS. b. The plan will establish, for individuals receiving or eligible to receive services through the HCBS waivers under this Agreement: i. Baseline information regarding the number of individuals who would choose the independent living options described above, if available; and ii. Recommendations to provide access to these settings during each year of this Agreement. 4. Within 365 days of this Agreement, the Commonwealth shall establish and begin distributing, from a one-time fund of $800,000 to provide and administer rental assistance in accordance with the recommendations described above in Section III.D.3.b.ii, to as many individuals as possible who receive HCBS waivers under this Agreement, express a desire for living in their own home or apartment, and for whom such a placement is the most integrated setting appropriate to their needs. 5. Individuals in the target population shall not be served in a sponsored home or any congregate setting, unless such placement is consistent with the individual s choice after receiving options for community placements, services, and supports consistent with the terms of Section IV.B.9 below. 6. No individual in the target population shall be placed in a nursing facility or congregate setting with five or more individuals unless such placement is consistent with the individual s needs and informed choice and has been reviewed by the Region s Community Resource Consultant and, under circumstances described in Section III.E below, by the Regional Support Team. 7. The Commonwealth shall include a term in the annual performance contract with the CSBs to require case managers to continue to offer education about less restrictive 12

13 community options on at least an annual basis to any individuals living outside their own home or family s home (and, if relevant, to their authorized representative or guardian). E. Community Resource Consultants and Regional Support Teams 1. The Commonwealth shall utilize Community Resource Consultant ( CRC ) positions located in each Region to provide oversight and guidance to CSBs and community providers, and serve as a liaison between the CSB case managers and DBHDS Central Office. The CRCs shall provide on-site, electronic, written, and telephonic technical assistance to CSB case managers and private providers regarding personcentered planning, the Supports Intensity Scale, and requirements of case management and HCBS Waivers. The CRC shall also provide ongoing technical assistance to CSBs and community providers during an individual s placement. The CRCs shall be a member of the Regional Support Team in the appropriate Region. 2. The CRC may consult at any time with the Regional Support Team. Upon referral to it, the Regional Support Team shall work with the Personal Support Team ( PST ) and CRC to review the case, resolve identified barriers, and ensure that the placement is the most integrated setting appropriate to the individual s needs, consistent with the individual s informed choice. The Regional Support Team shall have the authority to recommend additional steps by the PST and/or CRC. 3. The CRC shall refer cases to the Regional Support Teams for review, assistance in resolving barriers, or recommendations whenever: a. The PST is having difficulty identifying or locating a particular community placement, services and supports for an individual within 3 months of the individual s receipt of HCBS waiver services. b. The PST recommends and, upon his/her review, the CRC also recommends that an individual residing in his or her own home, his or her family s home, or a sponsored residence be placed in a congregate setting with five or more individuals. c. The PST recommends and, upon his/her review, the CRC also recommends an individual residing in any setting be placed in a nursing home or ICF. d. There is a pattern of an individual repeatedly being removed from his or her current placement. 13

14 IV. Discharge Planning and Transition from Training Center By July 2012, the Commonwealth will have implemented Discharge and Transition Planning processes at all Training Centers consistent with the terms of this Section, excluding other dates agreed upon, and listed separately in this Section. A. To ensure that individuals are served in the most integrated setting appropriate to their needs, the Commonwealth shall develop and implement discharge planning and transition processes at all Training Centers consistent with the terms of this Section and personcentered principles. B. Discharge Planning and Discharge Plans 1. Discharge planning shall begin upon admission. 2. Discharge planning shall drive treatment of individuals in any Training Center and shall adhere to the principles of person-centered planning. 3. Individuals in Training Centers shall participate in their treatment and discharge planning to the maximum extent practicable, regardless of whether they have authorized representatives. Individuals shall be provided the necessary support (including, but not limited to, communication supports) to ensure that they have a meaningful role in the process. 4. The goal of treatment and discharge planning shall be to assist the individual in achieving outcomes that promote the individual s growth, well being, and independence, based on the individual s strengths, needs, goals, and preferences, in the most integrated settings in all domains of the individual s life (including community living, activities, employment, education, recreation, healthcare, and relationships). 5. The Commonwealth shall ensure that discharge plans are developed for all individuals in its Training Centers through a documented person-centered planning and implementation process and consistent with the terms of this Section. The discharge plan shall be an individualized support plan for transition into the most integrated setting consistent with informed individual choice and needs and shall be implemented accordingly. The final discharge plan (developed within 30 days prior to discharge) will include: a. Provision of reliable information to the individual and, where applicable, the authorized representative, regarding community options in accordance with Section IV.B.9; b. Identification of the individual s strengths, preferences, needs (clinical and support), and desired outcomes; 14

15 c. Assessment of the specific supports and services that build on the individual s strengths and preferences to meet the individual s needs and achieve desired outcomes, regardless of whether those services and supports are currently available; d. Listing of specific providers that can provide the identified supports and services that build on the individual s strengths and preferences to meet the individual s needs and achieve desired outcomes; e. Documentation of barriers preventing the individual from transitioning to a more integrated setting and a plan for addressing those barriers. i. Such barriers shall not include the individual s disability or the severity of the disability. ii. For individuals with a history of re-admission or crises, the factors that led to re-admission or crises shall be identified and addressed. 6. Discharge planning will be done by the individual s PST. The PST includes the individual receiving services, the authorized representative (if any), CSB case manager, Training Center staff, and persons whom the individual has freely chosen or requested to participate (including but not limited to family members and close friends). Through a person-centered planning process, the PST will assess an individual s treatment, training, and habilitation needs and make recommendations for services, including recommendations of how the individual can be best served. 7. Discharge planning shall be based on the presumption that, with sufficient supports and services, all individuals (including individuals with complex behavioral and/or medical needs) can live in an integrated setting. 8. For individuals admitted to a Training Center after the date this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described herein within 30 days of admission. For all individuals residing in a Training Center on the date that this Agreement is signed by both parties, the Commonwealth shall ensure that a discharge plan is developed as described herein within six months of the effective date of this Agreement. 9. In developing discharge plans, PSTs, in collaboration with the CSB case manager, shall provide to individuals and, where applicable, their authorized representatives, specific options for types of community placements, services, and supports based on the discharge plan as described above, and the opportunity to discuss and meaningfully consider those options. 15

16 a. The individual shall be offered a choice of providers consistent with the individual s identified needs and preferences. b. PSTs and the CSB case manager shall coordinate with the specific type of community providers identified in the discharge plan as providing appropriate community-based services for the individual, to provide individuals, their families, and, where applicable, their authorized representative with opportunities to speak with those providers, visit community placements (including, where feasible, for overnight visits) and programs, and facilitate conversations and meetings with individuals currently living in the community and their families, before being asked to make a choice regarding options. The Commonwealth shall develop family-to-family and peer programs to facilitate these opportunities. c. PSTs and the CSB case managers shall assist the individual and, where applicable, their authorized representative in choosing a provider after providing the opportunities described above and ensure that providers are timely identified and engaged in preparing for the individual s transition. 10. The Commonwealth shall ensure that Training Center PSTs have sufficient knowledge about community services and supports to: propose appropriate options about how an individual s needs could be met in a more integrated setting; present individuals and their families with specific options for community placements, services, and supports; and, together with providers, answer individuals and families questions about community living. a. In collaboration with the CSBs and community providers, the Commonwealth shall develop and provide training and information for Training Center staff about the provisions of this Agreement, staff obligations under the Agreement, current community living options, the principles of person-centered planning, and any related departmental instructions. The training will be provided to all applicable disciplines and all PSTs. b. Person-centered thinking training will occur during initial orientation and through annual refresher courses. Competency will be determined through documented observation of PST meetings and through the use of person-centered thinking coaches and mentors. Each Training Center will have designated coaches who receive additional training. The coaches will provide guidance to PSTs to ensure implementation of the person-centered tools and skills. Coaches throughout the state will have regular and structured sessions with person-centered thinking mentors. These sessions will be designed to foster additional skill development and ensure implementation of person-centered thinking practices throughout all levels of the Training Centers. 16

17 11. In the event that an individual or, where applicable, authorized representative opposes the PST s proposed options for placement in a more integrated setting after being provided the information and opportunities described in Section IV.B.9, the Commonwealth shall ensure that PSTs: a. Identify and seek to resolve the concerns of individuals and/or their authorized representatives with regard to community placement; b. Develop and implement individualized strategies to address concerns and objections to community placement; and c. Document the steps taken to resolve the concerns of individuals and/or their authorized representatives and provide information about community placement. 12. All individuals in the Training Center shall be provided opportunities for engaging in community activities to the fullest extent practicable, consistent with their identified needs and preferences, even if the individual does not yet have a discharge plan for transitioning to the community. 13. The State shall ensure that information about barriers to discharge from involved providers, CSB case managers, Regional Support Teams, Community Integration Managers, and individuals ISPs is collected from the Training Centers and is aggregated and analyzed for ongoing quality improvement, discharge planning, and development of community-based services. 14. In the event that a PST makes a recommendation to maintain placement at a Training Center or to place an individual in a nursing home or congregate setting with five or more individuals, the decision shall be documented, and the PST shall identify the barriers to placement in a more integrated setting and describe in the discharge plan the steps the team will take to address the barriers. The case shall be referred to the Community Integration Manager and Regional Support Team in accordance with Sections IV.D.2.a and f and IV.D.3 below, and such placements shall only occur as permitted by Section IV.C.6. C. Transition to Community Setting 1. Once a specific provider is selected by an individual, the Commonwealth shall invite and encourage the provider to actively participate in the transition of the individual from the Training Center to the community placement. 2. Once trial visits are completed, the individual has selected a provider, and the provider agrees to serve the individual, discharge will occur within 6 weeks, absent conditions beyond the Commonwealth s control. If discharge does not occur within 6 weeks, the reasons it did not occur will be documented and a new time frame for 17

18 discharge will be developed by the PST. Where discharge does not occur within 3 months of selecting a provider, the PST shall identify the barriers to discharge and notify the Facility Director and Community Integration Manager in accordance with Section IV.D.2 below, and the case shall be referred to the Regional Support Teams in accordance with Section IV.D.3 below. 3. The Commonwealth shall develop and implement a system to follow up with individuals after discharge from the Training Centers to identify gaps in care and address proactively any such gaps to reduce the risk of re-admission, crises, or other negative outcomes. The Post Move Monitor, in coordination with the CSB, will conduct post-move monitoring visits within each of three (3) intervals (30, 60, and 90 days) following an individual s movement to the community setting. Documentation of the monitoring visit will be made using the Post Move Monitoring Checklist. The Commonwealth shall ensure those conducting Post Move Monitoring are adequately trained and a reasonable sample of look-behind Post Move Monitoring is completed to validate the reliability of the Post Move Monitoring process. 4. The Commonwealth shall ensure that each individual transitioning from a Training Center shall have a current discharge plan, updated within 30 days prior to the individual s discharge. 5. The Commonwealth shall ensure that the PST will identify all needed supports, protections, and services to ensure successful transition in the new living environment, including what is most important to the individual as it relates to community placement. The Commonwealth, in consultation with the PST, will determine the essential supports needed for successful and optimal community placement. The Commonwealth shall ensure that essential supports are in place at the individual s community placement prior to the individual s discharge from the Training Center. This determination will be documented. The absence of those services and supports identified as non-essential by the Commonwealth, in consultation with the PST, shall not be a barrier to transition. 6. No individual shall be transferred from a Training Center to a nursing home or congregate setting with five or more individuals unless placement in such a facility is in accordance with the individual s informed choice after receiving options for community placements, services, and supports and is reviewed by the Community Integration Manager to ensure such placement is consistent with the individual s informed choice. 7. The Commonwealth shall develop and implement quality assurance processes to ensure that discharge plans are developed and implemented, in a documented manner, consistent with the terms of this Agreement. These quality assurance processes shall be sufficient to show whether the objectives of this Agreement are being achieved. Whenever problems are identified, the Commonwealth shall develop and implement plans to remedy the problems. 18

19 D. Community Integration Managers and Regional Support Teams 1. The Commonwealth will create Community Integration Manager ( CIM ) positions at each operating Training Center. The CIMs will be DBHDS Central Office staff members who will be physically located at each of the operating Training Centers. The CIMs will facilitate communication and planning with individuals residing in the Training Centers, their families, the PST, and private providers about all aspects of an individual s transition, and will address identified barriers to discharge. The CIMs will have professional experience working in the field of developmental disabilities, and an understanding of best practices for providing community services to individuals with developmental disabilities. The CIMs will have expertise in the areas of working with clinical and programmatic staff, facilitating large, diverse groups of professionals, and providing service coordination across organizational boundaries. The CIMs will serve as the primary connection between the Training Center and DBHDS Central Office. The CIMs will provide oversight, guidance, and technical assistance to the PSTs by identifying strategies for addressing or overcoming barriers to discharge, ensuring that PSTs follow the process described in Sections IV.B and C above, and identifying and developing corrective actions, including the need for any additional training or involvement of supervisory staff. 2. CIMs shall be engaged in addressing barriers to discharge, including in all of the following circumstances: a. The PST recommends that an individual be transferred from a Training Center to a nursing home or congregate setting with five or more individuals; b. The PST is having difficulty identifying or locating a particular type of community placement, services and supports for an individual within 90 days of development of a discharge plan during the first year of the Agreement; within 60 days of development of a discharge plan during the second year of the Agreement; within 45 days of development of a discharge plan in the third year of the Agreement; and within 30 days of development of a discharge plan thereafter. c. The PST cannot agree on a discharge plan outcome within 15 days of the annual PST meeting, or within 30 days after the admission to the Training Center. d. The individual or his or her authorized representative opposes discharge after all the requirements described in Section IV.B.9 have been satisfied or refuses to participate in the discharge planning process; e. The individual is not discharged within three months of selecting a provider, as described in Section IV.C.2 above. The PST shall identify the barriers to discharge and notify both the facility director and the CIM; or 19

20 f. The PST recommends that an individual remain in a Training Center. If the individual remains at the Training Center, an assessment by the PST and the CIM will be performed at 90-day intervals from the decision for the individual to remain at the Training Center, to ensure that the individual is in the most integrated setting appropriate to his or her needs. 3. The Commonwealth will create five Regional Support Teams, each coordinated by the CIM. The Regional Support Teams shall be composed of professionals with expertise in serving individuals with developmental disabilities in the community, including individuals with complex behavioral and medical needs. Upon referral to it, the Regional Support Team shall work with the PST and CIM to review the case and resolve identified barriers. The Regional Support Team shall have the authority to recommend additional steps by the PST and/or CIM. The CIM may consult at any time with the Regional Support Teams and will refer cases to the Regional Support Teams when: a. The CIM is unable, within 2 weeks of the PST s referral to the CIM, to document attainable steps that will be taken to resolve any barriers to community placement enumerated in Section IV.D.2 above. b. A PST continues to recommend placement in a Training Center at the second quarterly review following the PST s recommendation that an individual remain in a Training Center (Section IV.D.2.f), and at all subsequent quarterly reviews that maintain the same recommendation. This paragraph shall not take effect until two years after the effective date of this Agreement. c. The CIM believes external review is needed to identify additional steps that can be taken to remove barriers to discharge. 4. The CIM shall provide monthly reports to DBHDS Central Office regarding the types of placements to which individuals have been placed, including recommendations that individuals remain at a Training Center. V. Quality and Risk Management System A. To ensure that all services for individuals receiving services under this Agreement are of good quality, meet individuals needs, and help individuals achieve positive outcomes, including avoidance of harms, stable community living, and increased integration, independence, and self-determination in all life domains (e.g., community living, employment, education, recreation, healthcare, and relationships), and to ensure that appropriate services are available and accessible for individuals in the target population, the Commonwealth shall develop and implement a quality and risk management system that is consistent with the terms of this Section. 20

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